Provider Demographics
NPI:1235137050
Name:BOSE, SHARMISTHA (PHD)
Entity Type:Individual
Prefix:MRS
First Name:SHARMISTHA
Middle Name:
Last Name:BOSE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 ILLINOIS AVE
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2963
Mailing Address - Country:US
Mailing Address - Phone:630-377-3535
Mailing Address - Fax:630-530-9527
Practice Address - Street 1:405 ILLINOIS AVE
Practice Address - Street 2:SUITE 2C
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2963
Practice Address - Country:US
Practice Address - Phone:630-377-3535
Practice Address - Fax:630-530-9527
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005939103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist